The Health and Safety Incident Report Form is a critical document required under Canadian workplace safety legislation, designed to ensure proper documentation and investigation of workplace incidents. This form must be completed whenever a workplace accident, injury, illness, or near-miss occurs, in accordance with both federal requirements under the Canada Labour Code and applicable provincial occupational health and safety regulations. It serves multiple purposes: documenting incidents for legal compliance, initiating investigations, supporting workers' compensation claims, identifying workplace hazards, and developing preventive measures. The form includes mandatory fields aligned with regulatory requirements while maintaining confidentiality standards under privacy legislation. It is an essential tool for maintaining workplace safety records and supporting continuous improvement in organizational safety practices.
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1. Incident Identification: Basic information including date, time, location, and reference number of the incident
2. Reporter Details: Information about the person completing the report including name, position, contact details
3. Affected Person(s) Information: Details of all persons involved in or affected by the incident, including employees, contractors, visitors
4. Incident Details: Comprehensive description of what happened, including sequence of events, type of incident, and immediate actions taken
5. Injury/Illness Information: Specific details about any injuries or illnesses resulting from the incident, including type and severity
6. Witness Information: Details of any witnesses to the incident, including contact information and initial statements
7. Initial Response: Actions taken immediately following the incident, including first aid, emergency services called
8. Root Cause Analysis: Initial assessment of what caused the incident, including contributing factors
9. Immediate Corrective Actions: Details of actions taken to prevent immediate recurrence and make the area safe
10. Notifications Made: List of all parties notified about the incident (supervisors, regulators, etc.) and timing of notifications
1. Environmental Impact: To be included when incident involves environmental spills, releases, or damage
2. Equipment/Property Damage: To be included when incident involves damage to equipment, vehicles, or property
3. Hazardous Materials: To be included when incident involves dangerous goods or hazardous substances
4. Security Incident Details: To be included for incidents involving security breaches or threats
5. Third Party Involvement: To be included when incident involves contractors, visitors, or members of the public
6. Media Contact: To be included when incident has attracted or may attract media attention
1. Appendix A - Injury Classification Guide: Reference guide for classifying type and severity of injuries
2. Appendix B - Site Map/Location Diagram: Template for marking incident location and relevant surrounding areas
3. Appendix C - Witness Statement Form: Detailed witness statement template for gathering comprehensive witness accounts
4. Appendix D - Photo Log: Template for documenting and cataloging incident scene photographs
5. Appendix E - Risk Matrix: Guide for assessing incident severity and potential consequences
6. Appendix F - Regulatory Reporting Requirements: Reference guide for mandatory reporting requirements by incident type
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